Orbital Cellulitis Follow-up

  • Author: John N Harrington, MD, FACS; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 9, 2012
 

Further Inpatient Care

Closely monitor the patient (at least daily), with vision reevaluated by standardized vision testing, as appropriate, and preferably by the same examiner. Evaluate the antibiotic coverage daily and change as needed depending on the results of cultures and the patient's clinical course.[19] Repeat CT scans if the patient's condition worsens or does not respond to appropriate antibiotics.

Once the patient is clearly improving and has been afebrile for at least 48 hours, the patient can be changed from intravenous antibiotics to oral antibiotics (eg, ampicillin, cefpodoxime, cefuroxime, cefprozil) for aerobic infections or metronidazole for anaerobic infections.

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Further Outpatient Care

The patient should be monitored by an infectious disease specialist, as well as an ophthalmologist, until the infectious disease specialist believes that the medications can be discontinued.

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Inpatient & Outpatient Medications

See Medication.

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Transfer

If necessary, the patient may be transferred for further diagnostic evaluation or for surgical intervention.

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Deterrence/Prevention

No foolproof method for the prevention of orbital cellulitis exists; however, proper treatment of conditions that may precipitate orbital cellulitis (eg, preseptal cellulitis, sinusitis, dental disease) is the best deterrent.

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Complications

Either orbital or intracranial complications of orbital cellulitis may occur. Subperiorbital or orbital abscess formation may occur (7-9%) or permanent vision loss may occur from corneal damage secondary to exposure or neurotrophic keratitis, destruction of intraocular tissues, secondary glaucoma, optic neuritis, or central retinal artery occlusion. Blindness also may occur secondary to elevated intraorbital pressure or direct extension of infection to the optic nerve from the sphenoid sinus. Direct involvement of the ocular motor nerves or the extraocular muscles may lead to decreased ocular motility.

Intracranial complications include meningitis (2%), cavernous sinus thrombosis (1%), and intracranial, epidural, or subdural abscess formation. Although cavernous sinus thrombosis has become relatively rare in developed countries with proper treatment, it has a mortality rate of 50% or higher. Cavernous sinus should be considered in any patient with orbital cellulitis and suspected in the presence of rapid progression of the clinical signs (eg, increasing proptosis, mydriasis, dilation of retinal veins, decreasing visual acuity, development of an afferent pupillary defect).

Intracranial abscess formation is suggested by altered consciousness, signs of central nervous system disturbance, persistent fever despite adequate antibiotic therapy, and resolution of the sinusitis and orbital cellulitis components of the disease.

Orbital cellulitis resulting from sinusitis usually can be distinguished easily from other causes of acute inflammatory proptosis by clinical signs, CT scans, and assessment of risk factors.

Cavernous sinus thrombosis, a serious complication of paranasal sinusitis that most commonly results from anterograde spread from infection involving the mid third of the face (eg, orbit, mouth, paranasal sinuses), may be difficult to distinguish from simple orbital cellulitis. It may occur with and be caused by orbital cellulitis. A patient with cavernous sinus thrombosis without orbital cellulitis will show marked restriction of ocular motility out of proportion to the degree of proptosis. A patient also will have normal retropulsion of the globe, hypesthesia in the distribution of the first and second divisions of the trigeminal nerve, dilated retinal veins, orbital congestion, and possibly neurologic defects (eg, altered sensorium). A cranial MRI can help confirm the diagnosis of cavernous sinus thrombosis.

Orbital pseudotumor may cause rapidly developing orbital congestion, proptosis, and limitation of motility, but it typically occurs in older age groups. Orbital echography may be helpful in differentiation.

Usually, endocrine orbitopathy may be identified by its typical clinical features. Orbital myositis may produce mild vascular congestion and proptosis. A fast-growing necrotic retinoblastoma may produce mild vascular congestion, proptosis, and rhabdomyosarcoma. Metastatic orbital tumor, especially breast carcinoma, may give similar findings.

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Patient Education

For excellent patient education resources, see eMedicine's Diabetes Center. Also, visit eMedicine's patient education article Cellulitis.

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Contributor Information and Disclosures
Author

John N Harrington, MD, FACS  Director of Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology, Baylor University Medical Center; Clinical Professor Emeritus, Department of Ophthalmology, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School

John N Harrington, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, and Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Brian A Phillpotts, MD  Former Vitreo-Retinal Service Director, Former Program Director, Clinical Assistant Professor, Department of Ophthalmology, Howard University College of Medicine

Brian A Phillpotts, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Medical Association, and National Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark T Duffy, MD, PhD  Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic

Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience

Disclosure: Allergan - Botox Cosmetic Honoraria Speaking and teaching

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

  1. Anari S, Karagama YG, Fulton B, et al. Neonatal disseminated methicillin-resistant Staphylococcus aureus presenting as orbital cellulitis. J Laryngol Otol. Jan 2005;119(1):64-7. [Medline].

  2. Blomquist PH. Methicillin-resistant Staphylococcus aureus infections of the eye and orbit (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2006;104:322-45. [Medline].

  3. Boden JH, Ainbinder DJ. Methicillin-resistant ascending facial and orbital cellulitis in an operation Iraqi Freedom troop population. Ophthal Plast Reconstr Surg. Sep-Oct 2007;23(5):397-9. [Medline].

  4. Hollsten J, Hollsten D, Green, MK. Orbital community-acquired methicillin-resistant Staphylococcus aureus infections: the range of presentation, increasing prevalence and efficacy of treatment. Poster at Fall Scientific Symposium, American Society of Ophthalmic Plastic and Reconstructive Surgery. Nov 2008.

  5. Rutar T, Chambers HF, Crawford JB, et al. Ophthalmic manifestations of infections caused by the USA300 clone of community-associated methicillin-resistant Staphylococcus aureus. Ophthalmology. Aug 2006;113(8):1455-62. [Medline].

  6. Rutar T, Zwick OM, Cockerham KP, et al. Bilateral blindness from orbital cellulitis caused by community-acquired methicillin-resistant Staphylococcus aureus. Am J Ophthalmol. Oct 2005;140(4):740-2. [Medline].

  7. McKinley SH, Yen MT, Miller AM, et al. Microbiology of pediatric orbital cellulitis. Am J Ophthalmol. Oct 2007;144(4):497-501. [Medline].

  8. Nageswaran S, Woods CR, Benjamin DK Jr, et al. Orbital cellulitis in children. Pediatr Infect Dis J. Aug 2006;25(8):695-9. [Medline].

  9. Grimes D, Fan K, Huppa C. Case report: dental infection leading to orbital cellulitis. Dent Update. May 2006;33(4):217-8, 220. [Medline].

  10. Babar TF, Zaman M, Khan MN, Khan MD. Risk factors of preseptal and orbital cellulitis. J Coll Physicians Surg Pak. Jan 2009;19(1):39-42. [Medline].

  11. Kloek CE, Rubin PA. Role of inflammation in orbital cellulitis. Int Ophthalmol Clin. Spring 2006;46(2):57-68. [Medline].

  12. Chiu ES, Capel B, Press R, et al. Successful management of orbital cellulitis and temporary visual loss after blepharoplasty. Plast Reconstr Surg. Sep 2006;118(3):67e-72e. [Medline].

  13. Ferry AP, Abedi S. Diagnosis and management of rhino-orbitocerebral mucormycosis (phycomycosis). A report of 16 personally observed cases. Ophthalmology. Sep 1983;90(9):1096-104. [Medline].

  14. Gass JD. Ocular manifestations of acute mucormycosis. Arch Ophthalmol. Feb 1961;65:226-37. [Medline].

  15. Sridhara SR, Paragache G, Panda NK, et al. Mucormycosis in immunocompetent individuals: an increasing trend. J Otolaryngol. Dec 2005;34(6):402-6. [Medline].

  16. Yen MT, Yen KG. Effect of corticosteroids in the acute management of pediatric orbital cellulitis with subperiosteal abscess. Ophthal Plast Reconstr Surg. Sep 2005;21(5):363-6; discussion 366-7. [Medline].

  17. Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988-1998. Ophthalmology. Aug 2000;107(8):1454-6; discussion 1457-8. [Medline].

  18. Emmett Hurley P, Harris GJ. Subperiosteal abscess of the orbit: duration of intravenous antibiotic therapy in nonsurgical cases. Ophthal Plast Reconstr Surg. Jan 2012;28(1):22-6. [Medline].

  19. Vayalumkal JV, Jadavji T. Children hospitalized with skin and soft tissue infections: a guide to antibacterial selection and treatment. Paediatr Drugs. 2006;8(2):99-111. [Medline].

  20. Bergin DJ, Wright JE. Orbital cellulitis. Br J Ophthalmol. Mar 1986;70(3):174-8. [Medline].

  21. Bullock JD, Fleishman JA. Orbital cellulitis following dental extraction. Trans Am Ophthalmol Soc. 1984;82:111-33. [Medline].

  22. Denning DW, Stevens DA. Antifungal and surgical treatment of invasive aspergillosis: review of 2,121 published cases. Rev Infect Dis. Nov-Dec 1990;12(6):1147-201. [Medline].

  23. Dortzbach RK, Segrest DR. Orbital aspergillosis. Ophthalmic Surg. Mar 1983;14(3):240-4. [Medline].

  24. Doxanas MT, Anderson RL. Clinical Orbital Anatomy. Baltimore, Md: Williams & Wilkins;1984.

  25. Harris GJ. Subperiosteal abscess of the orbit. Arch Ophthalmol. May 1983;101(5):751-7. [Medline].

  26. Harris GJ. Subperiosteal inflammation of the orbit. A bacteriological analysis of 17 cases. Arch Ophthalmol. Jul 1988;106(7):947-52. [Medline].

  27. Harris GJ, Will BR. Orbital aspergillosis. Conservative debridement and local amphotericin irrigation. Ophthal Plast Reconstr Surg. 1989;5(3):207-11. [Medline].

  28. Hornblass A, Herschorn BJ, Stern K, et al. Orbital abscess. Surv Ophthalmol. Nov-Dec 1984;29(3):169-78. [Medline].

  29. Jackson K, Baker SR. Clinical implications of orbital cellulitis. Laryngoscope. May 1986;96(5):568-74. [Medline].

  30. Jones DB, Steinkuller PG. Strategies for the initial management of acute preseptal and orbital cellulitis. Trans Am Ophthalmol Soc. 1988;86:94-108; discussion 108-12. [Medline].

  31. Jordan DR, St Onge P, Anderson RL, et al. Complications associated with alloplastic implants used in orbital fracture repair. Ophthalmology. Oct 1992;99(10):1600-8. [Medline].

  32. Koornneef L. Orbital septa: anatomy and function. Ophthalmology. May 1979;86(5):876-80. [Medline].

  33. Lemke BN, Gonnering RS, Weinstein JM. Orbital cellulitis with periosteal elevation. Ophthal Plast Reconstr Surg. 1987;3(1):1-7. [Medline].

  34. Mauriello JA Jr, Hargrave S, Yee S, et al. Infection after insertion of alloplastic orbital floor implants. Am J Ophthalmol. Feb 15 1994;117(2):246-52. [Medline].

  35. Schramm VL Jr, Curtin HD, Kennerdell JS. Evaluation of orbital cellulitis and results of treatment. Laryngoscope. Jul 1982;92(7 Pt 1):732-8. [Medline].

  36. Shields JA, Shields CL, Suvarnamani C, et al. Retinoblastoma manifesting as orbital cellulitis. Am J Ophthalmol. Oct 15 1991;112(4):442-9. [Medline].

  37. Steinkuller PG, Jones DB. Microbial preseptal and orbital cellulitis. In: Tasman W, ed. Clinical Ophthalmology. Philadelphia, Pa: Lippincott, Williams & Wilkins; 1999:1-8, 17-29, Chap 25.

  38. Westley GJ, Mazur JM, Sifton DW, eds. Physicians' Desk Reference. Vol 52. Montvale, NJ: Medical Economics Co; 1998:2081, 2145.

 
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A male patient with orbital cellulitis with proptosis, ophthalmoplegia, and edema and erythema of the eyelids. The patient also exhibited pain on eye movement, fever, headache, and malaise.
A male patient with orbital cellulitis with proptosis, ophthalmoplegia, and edema and erythema of the eyelids. The patient also exhibited chemosis and resistance to retropulsion of the globe.
 
 
 
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